A resident with dementia, behavioral symptoms, and multiple psychotropic and cardiovascular medications was discharged to another nursing facility without a thorough or accurate discharge summary. The care plan contained a discharge planning focus but was never updated to reflect the actual discharge, and the EHR lacked documentation of discharge planning, the reason for discharge, or a recapitulation of stay, despite a family member stating they initiated the discharge due to dissatisfaction with care. The discharge instructions contained multiple medication discrepancies and omissions, including missing drugs, incorrect dosages, and absent administration frequencies, and several PRN constipation medications were not listed, contrary to the facility’s written discharge planning policy.
Failure to Notify Ombudsman of Resident Transfers: The facility did not notify the LTC Ombudsman of hospital transfers/discharges for two residents. One resident was discharged to an acute care hospital and was not expected to return, but was not listed on the monthly transfer/discharge notice. Another resident had severe RUQ pain, purplish lips, and pursed-lip breathing, was sent by ambulance to the ED, and later returned the same day, but was also omitted from the Ombudsman notice. The Administrator stated one notification was missed and said she did not know emergency transfers required notification if the resident was not admitted.
Missing Written Bed Hold Notification Before Hospital Transfers: The facility failed to provide written bed hold information to two residents or their representatives before hospital transfers. One resident had severe cognitive impairment, respiratory failure, and ESRD on dialysis and was sent from the dialysis center for low O2 saturation; the other had intact cognition, osteomyelitis, and muscle weakness and was transferred for a hip fracture. Records lacked documentation of bed hold notification for either transfer, and the Administrator could not locate the required information.
Failure to notify the LTC Ombudsman of two resident moves: one resident with moderately impaired cognition was sent to the hospital after a fall and returned shortly after, and another resident with intact cognition was discharged home with family. The facility's transfer/discharge form did not show Ombudsman notification for either event, and the Administrator said one was missed because the stay away was brief and the other because it occurred on a weekend.
Failure to provide written transfer, ombudsman, and bed-hold notifications: The facility did not give the resident representative written notice of a hospital transfer or notify the state ombudsman for one resident, and it did not document bed-hold and reserve bed payment information for two residents. One resident had severe cognitive impairment and was transferred after a fall, while another resident with cancer, HF, and respiratory failure was transferred for breathing difficulty and later diagnosed with PNA. Staff stated the transfers were emergent and could not locate the required written documentation.
Missing transfer documentation for hospitalized residents. The facility failed to keep records of the information sent with two residents during four hospital transfers. Review of progress notes and assessments showed no documentation of the MAR, TAR, IPOST, face sheet, bed hold form, vital signs, or verbal reports that the DON expected staff to provide to EMTs and the ER, and the DON and Administrator stated the facility did not have a written discharge policy or procedure.
Missing Ombudsman Notification and Discharge Summary Documentation: The facility failed to include a resident on the LTCO transfer/discharge report after a hospital transfer and return, even though the EHR was expected to pull discharged residents automatically. The facility also lacked a discharge summary for another resident after discharge, and the DON acknowledged the summary was not completed as required by policy.
A resident discharged AMA was not included on the notice to the LTC Ombudsman because the resident did not appear on the Action Summary report. EHR documentation showed STOP BILLING and a progress note confirming the AMA discharge, but the Ombudsman notice did not list the resident. The Administrator stated the LTC Ombudsman should be notified of discharges, and the facility had no policy directing that notification.
Missing discharge recapitulation of stay. The facility failed to complete discharge summaries for two residents who were discharged from skilled services. Both residents had no cognitive impairment on BIMS, and the records showed discharge-related billing changes and discharge plans, but the charts lacked the required recapitulation of stay, including diagnoses and course of treatment. The DON stated that if it was not in the assessments then it was not completed.
Incomplete hospital transfer documentation was found for two residents whose records lacked copies of transfer paperwork. One resident was cognitively intact, dependent for transfers, and had diagnoses including malnutrition, a pressure ulcer, and paraplegia; the other was cognitively intact with paraplegia, diabetes, and anxiety and was transferred for sepsis and a UTI. The DON stated the nurse failed to copy the paperwork sent with both residents, and staff identified required transfer documents such as the Resident Transfer Sheet/Record, MAR, TAR, immunization records, advance directives, and pertinent lab or x-ray results.
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